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Addressing health systems challenges for diabetes care in Pakistan

POLICY BRIEF

Key message:

Integrating diabetes management into routine primary care is feasible and acceptable, and can lead to improved assessment, diagnosis, prescription practices, patient education and adherence to follow-up appointments.

Based on our research, we make 5 recommendations to address health systems challenges for diabetes care in Pakistan:

Add more specific diabetes and hypertension drugs to the essential drugs list to improve supply at primary healthcare centres. The availability of drugs influenced the prescription rates at respective facilities.

Invest in further staff supervision and support to help achieve universal adherence to the prescription protocols. The study found that one third of doctors varied their prescriptions from the standards set out.

Keep the prescription protocols simple. We found a very low prescription rate of preventive medicine, even when the medicine was made available.

Use random blood glucose (RBG) testing at follow-up instead of fasting blood glucose (FBG) RBG at follow-up is more feasible for patients than FBG. FBG involves more effort for patients and staff, yet does not necessarily improve the quality of clinical care. RBG can be used as a reasonable test to check the glycaemic control of patients in poor country settings.

Make urine testing of diabetes patients universally available at primary healthcare facilities. 40% of diabetic patients had some degree of proteinuria. This study showed that using a urine dipstick makes urine testing more feasible in primary healthcare settings.

The intervention:

The intervention package was found to be feasible in delivering quality CVD/diabetes care in rural healthcare facilities. The package includes:

screening of overweight adults;

standardised diagnosis;

lifestyle education about diet, exercise and quitting smoking;

standardised drug treatment for diabetes hypertension and hyperlipidaemia; and

active follow-up of patients.

The intervention also includes enhanced care delivery and management support, for example, drug supply, staff training and care monitoring.

Methods:

We evaluated the processes of a complex intervention to strengthen diabetes management in primary healthcare in Pakistan. The intervention included evidence-based clinical and operational guidelines, as well as training and recording tools for use within primary healthcare facilities. We used mixed quantitative and qualitative methods, employed sequentially.